Survey Consent Form

Attachment F. Survey Consent Form
Model Aquatic Health Code (MAHC) Use and Implementation Survey
Please read and sign this sheet before completing the survey.
Thank you for agreeing to provide feedback on your jurisdiction’s recreational water public health program
and use of the Model Aquatic Health Code (MAHC). Your participation will help CDC understand how
the MAHC is meeting the needs of recreational water programs across State, Territorial, Local, and Tribal
health departments in the United States.
Participation in this survey is completely voluntary. This survey is estimated to take 20–30 minutes to
complete. We ask that you take this time to share your experiences and opinions, which are essential in
helping us provide the best public health guidance possible. If you need to save your responses and submit
the survey at a later time, you will be able to do so.
At the end of the survey, you will be asked if you are willing to participate in further discussions (e.g., focus
groups, interviews) with CDC about your jurisdiction’s public aquatic facility safety and regulation
program. If you do not wish to be contacted further about these discussions, please do not list your contact
information and your survey results will remain anonymous.

By initialing this page, you acknowledge that you understand, agree to, and consent to the above
statements.
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Initials
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Date